It’s World Antibiotic Awareness Week, which aims highlight the problem of antibiotic resistance and encourage best practice in antibiotic use. Last week, a new Cochrane review was published which found that helping doctors and patients decide together about using antibiotics to treat some respiratory infections probably results in fewer being prescribed. In this guest blog, retired GP Richard Lehman explains why this is a good thing.

It’s that time of year again. Most of us “come down” with something during the winter months. This is my first winter after complete retirement from general practice, so I can fall ill at leisure. I don’t have to worry about seeing endless worried parents of children with earache or croup, or adults whose cough has gone on for two weeks. Many of them come expecting antibiotics, and in the hurly burly of a busy surgery around Christmas, the temptation is to go ahead and hand them out.

Symptoms caused by common viruses go on a lot longer than many people realize

There are a number of reasons why this is not a good idea. First of all, the symptoms caused by common viruses go on a lot longer than many people realize. Earache lasting three or four days, or a cough lasting for over two weeks, are usually just features of a cold virus which has either reached the middle ear or is causing a continuing reaction in the upper air passages. Producing green nasal discharge or phlegm is normal with these viral infections, and will almost always clear up on its own within a few days. Sore throats also usually resolve on their own, even if there is some involvement from bacteria, usually streptococci. Following flu, it’s quite normal to feel lousy for two or more weeks and to have a troublesome cough, especially at night. Nobody has yet come up with anything very useful for these symptoms, let alone anything that will shorten the illness.

Antibiotics don’t work for uncomplicated viral illnesses in healthy people

The main reason not to prescribe antibiotics, then, is that they don’t work for uncomplicated viral illnesses in healthy people, children or adults. The second reason is that for such people, they are more likely to cause a reaction – a skin eruption, nausea, diarrhoea, oral or vaginal thrush – than they are to help the illness. Thirdly, for a year after taking them, the bacteria in your body are more likely to be resistant to that antibiotic, making it less likely to work when really needed. And fourthly, if antibiotics are widely used in the community, most of the bacteria in the community become resistant.

In not taking antibiotics you are avoiding a useless treatment which might harm you

I’m putting the reasons in that order because there is a misperception that by not taking antibiotics you are risking harm to yourself for some vague benefit to others. In fact you are avoiding a useless treatment which might harm you personally. In the UK, antibiotic resistance in the bacteria which cause serious respiratory illnesses has not become a widespread problem, probably because antibiotic prescribing here is stable and lower than in many other European countries. But that threat always lurks as a possibility in the future.

It’s probable that most people who come to see doctors for these conditions would be less likely to want antibiotics if they had a full outline of the facts, either in conversation with a health professional or with the aid of a short written decision aid. This idea has been tested in nine trials involving nearly half a million patients. In an imperfect world, it was impossible to track each patient and discover exactly what happened to each of them, but it is clear that using some kind of shared decision making reduced antibiotic use without increasing the number of people who came back dissatisfied.

Shared decision making should be just what it says it is

Some sceptics would argue that this shows that “Shared decision making” is just another method that doctors use to tell patients what to do because they know best. But that should not be the way it works at all. Shared decision making should be just what it says it is: a way of agreeing decisions by discussing information which should be as easily available to the patient as the doctor. Some would go further and say that it will improve medicine by ensuring that doctors are as well informed as their patients. Bring it on, say I.

About Richard Lehman

Richard Lehman, MA, BM, BCh, MRCGP, is Professor of the Shared Understanding of Medicine in the Institute of Applied Health Research at the University of Birmingham. He was a general practitioner in Banbury for 37 years. For the last 20 years he has also written a weekly summary of articles from the principal medical journals which was posted on the BMJ website. After retirement from full-time general practice in 2010 he worked initially on studies of patient experiences, and spent a year at Yale University working on patient-centred outcomes and helping to set up the Yale Open Data Access (YODA) project. He remains a consultant to the group.
He is on the steering committees of the NICE shared decision making initiative and Academy of Medical Royal Colleges Choosing Wisely group. He was guest editor for the Sharing Medicine series in JAMA Internal Medicine (Sep 2017).

1 Comments on this post

[…] the use of antibiotics. Check out an excellent blog from Evidently Cochrane that suggests that shared decision making between doctors and patients is one way that unneccessary antibiotic prescrib…. Secondly, as a potential patient yourself seeking treatment in future, be prepared that in some […]

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